RU2482801C2 - Method of diaphragm plasty in case of post-trauma diaphragmatic hernia - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to surgery and can be applied for treatment of diaphragm injury with destruction of esophageal lumen of diaphragm. Section of diaphragm on feeding pedicle, which is unfolded on axis to esophagus and sewn to opposite pedicle, thus forming esophageal opening which corresponds to esophagus diameter, is cut out and mobilised from diaphragm, adjacent to destroyed esophageal lumen. Defect in diaphragm is covered by means of synthetic endoprosthesis, which is sewn on the entire perimetre of present defect with absorbable and non-absorbable threads.

EFFECT: method makes it possible to prevent development of commissural process between esophagus wall and endoprosthesis.

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Description

The invention relates to medicine, namely to surgery, and can be used in the treatment of patients with post-traumatic giant hernia and destruction of the esophageal opening of the diaphragm.

Currently, in case of giant post-traumatic hernia of the diaphragm with destruction of the esophagus, a method is used in which thoracotomy is performed on the side of the hernia, the abdominal organs displaced into the pleural cavity are reduced into the abdominal cavity, and then the diaphragm defect is closed with a polypropylene mesh endoprosthesis. At the same time, a new esophageal opening of the diaphragm is formed from the edges (1).

The disadvantages of this method are the development of an adhesion process between the wall of the esophagus and the endoprosthesis, limiting its mobility, impaired function, the formation of stenosis due to compression from the outside, ulceration.

There is a known method of surgery for cardiospasm, in which to protect the esophagus wall after dissection of its muscle layer, a fragment of its wall on the leg is cut out of the diaphragm, which is sutured to its muscular membrane, covering the submucous membrane of the esophagus wall from the outside, and then the defect in the diaphragm is sutured with interrupted sutures (2 )

The disadvantage of this method is the development of tension along the edges of the diaphragm along the line of suturing with the development of their insolvency, with the formation of a defect in it and recurrence of a hernia.

The aim of the invention is the restoration of the esophageal opening of the diaphragm due to the tissue of the diaphragm and closing the defect in it using a synthetic endoprosthesis.

This goal is achieved by performing left-sided thoracotomy in the 6th intercostal space, after lowering the abdominal organs (stomach, transverse colon, loops of the small intestine and large omentum) from the pleural cavity into the abdominal cavity, the legs of the diaphragm are formed, forming an esophageal opening in it. Then, from the diaphragm adjacent to the destroyed esophageal opening, a portion of the diaphragm is cut and mobilized on a 4 × 7 cm feeding leg, which is rotated along the axis to the esophagus with a 90 ° rotation and is sutured to the opposite leg using absorbable (Vicryl 2/0) threads thus forming the esophagus opening corresponding to the diameter of the esophagus. After this, the defect in the diaphragm is closed with a synthetic endoprosthesis of the corresponding size, which is hemmed around the entire perimeter of the defect with absorbable Vicryl 2/0 threads and non-absorbable Prolen 2/0 threads. The operation is completed by drainage of the pleural and abdominal cavities according to Byulau (taking into account the leakage of the polypropylene endoprosthesis before it is filled with fibrin), expansion of the lung and suturing of the wound on the chest.

The technical result of the proposed method for diaphragm plasty is the absence of adhesions between the esophagus wall and the endoprosthesis, since direct contact of the polypropylene mesh with the esophagus wall is excluded, as well as a decrease in the risk of hernia recurrence.

Clinical example: patient G., 28 years old, was hospitalized in the surgical department No. 6 of MMU "City Hospital No. 1 named after N.I. Pirogov ", Mr. Samara, December 16, 2009. Upon admission, he complained of pain in the left half of the chest, noisy breathing during sleep, a feeling of "gurgling" and rumbling in the left half of the chest, shortness of breath when moving to a horizontal position. From the anamnesis it was found that in July 2007 he suffered in a traffic accident. He was treated in the trauma department, where the intramedullary osteosynthesis of the left thigh was performed. In September 2009, the above complaints appeared. On December 8, 2009, due to a rise in temperature to 39 ° C and the appearance of a cough with scanty sputum, an ambulance team was hospitalized in the pulmonology department with a diagnosis of left-sided pneumonia, left-sided pleurisy. After an X-ray examination and consultation of a thoracic surgeon, the diagnosis was made: Post-traumatic diaphragmatic hernia on the left, left-sided pneumonia. The patient was sent to the surgical department.

December 17, 2009 the patient was operated on. Thoracotomy in the 6th intercostal space on the left. In the pleural cavity, the entire stomach, transverse colon, loops of the small intestine and large omentum were found. The lower lobe of the left lung is collapsed. During revision in the diaphragm, a defect 10 × 20 cm in size is determined, through which the organs of the abdominal cavity are displaced into the left pleural cavity. Due to the length of the process, mobilization of organs from adhesions to the defect in the diaphragm was required, after which they were moved to the abdominal cavity. The edges of the defect in the diaphragm are fibrically changed, the anterior semicircle of the esophageal opening is completely destroyed. The abdominal segment of the esophagus lies freely. The mobilization of the esophagus in the pleural cavity with the intersection of the ligament Morozov. The esophagus is taken on a holder and retracted anteriorly. Fixation sutures are placed behind the esophagus on the right and left legs of the diaphragm. Then, the anterior semicircle of the esophageal opening of the diaphragm was formed from the 4 × 7 cm diaphragm mobilized on the leg with a 90 ° rotation. The defect in the diaphragm was closed with a polypropylene endoprosthesis, hemmed to its edges around the entire defect with absorbable 2/0 Vicryl and non-absorbable Prolen 2/0. After drainage of the abdominal and pleural cavity, the chest wound is sutured. Both drains were connected according to Bulau, given that the synthetic endoprosthesis is not leakproof. The postoperative course is smooth. Drainages from the abdominal and pleural cavities removed on the 5th day. During the control x-ray, the location of the esophagus and stomach is normal, the left lung is straightened, the mobility of the left dome of the diaphragm is preserved. Discharged on December 31, 2009. Examined after 1 year, no complaints, working in the same specialty.

The proposed approach in the treatment of a patient with post-traumatic diaphragmatic hernia using a synthetic endoprosthesis made it possible to exclude direct contact of the polypropylene mesh with the esophagus wall, which eliminates the development of possible complications.

INFORMATION SOURCES:

1. Omarov I.Sh. Diagnosis and surgical treatment of rupture of the diaphragm with a closed injury to the chest and abdomen. Abstract of dissertation for the candidate of medical sciences, St. Petersburg, 2007.

2. Anthology of the history of Russian surgery. Volume IV B.V. Petrovsky. Selected Works. - S.185-195.

Claims (1)

A method of treating damage to the diaphragm with destruction of the esophageal opening of the diaphragm, including thoracotomy, lowering the abdominal organs from the chest cavity to the abdominal cavity, closing the defect in the diaphragm using a synthetic endoprosthesis, forming and esophageal opening, characterized in that from the diaphragm adjacent to the destroyed esophageal opening, they cut out and mobilize a portion of the diaphragm on the feeding leg, which is rotated axially to the esophagus and is sutured to the opposite leg, thereby forming the esophageal opening TIFA corresponding to the diameter of the esophagus, and the defect in the diaphragm closed with a synthetic prosthesis, which is sutured around the perimeter of the defect by using an existing absorbable and nonabsorbable filaments.